Saturday, November 21, 2009

I can always use money. Regardless of what the public seems to think, doctors are generally not phenomenally wealthy.

So I hate turning business away. But tonight I refused a hospital consult. Why would I do that?

Because.

The consult was for an 88 year old lady with advanced Alzheimer's Disease. Her sad life was reduced to lying in bed staring at the ceiling.

The patient had been seen by 2 other neurologists during this admission, and 3 others in the year previously. All had told the family the same sad facts of the case.

Yet, the family called me last night for a 6th opinion. A granddaughter poured out this sad story to me, and begged me to come see Grandma.

I asked her exactly why she wanted me to come in, since it didn't sound like I had much to add. Grandma has already had every test in the book.

So granddaughter said "Because the other neurologists just keep giving us bad news, and tell us to call hospice. We're looking for someone who will tell us this can be reversed, and who can fix her."

And that's why I turned down the consult. Because I'm not going to be a party to this insanity just to collect $100 from Medicare. It's not fair to anyone, especially Grandma. I bet she'd be horrified if she knew what was being done.

This is sad. But I won't be part of this family's denial issues. Me telling them the bad news for a 6th time obviously isn't going to change their actions. They'll just keep looking for someone who is either incompetent or willing to lie.

And that's why I turned it down. Because I respect Grandma. I'll never know who she was, but I doubt she'd want more docs being a part of her family's inability to let her life go with dignity.

My grandfather - who himself had been a GP - received some of the worst care of his life in his last year because certain family members refused to believe he really had Alzheimers. This was despite what were very clearly delusions on his part, and despite his being brought home numerous times by the police, completely unaware of where he'd been trying to go.

It's heartbreaking, but the kindest thing is to acknowledge what is happening and to preserve whatever comfort and dignity are left to the patient.

Thank you for having the courage to refuse the consult, Dr. Grumpy. I've been reading your blog for some time and you never fail to make me laugh. Tonight you made me cry. My 93 year old father has Alzheimer's and when his days come to an end, I will be there to hold his hand and let him go with all the dignity he deserves. In the meantime, I simply try to join his journey and never correct him when he tells me about the visit he just had with his (long dead) brothers. It's difficult, but he's usually happy wherever his mind takes him these days, and I'd like to join him there as much as I can.Thank you for not contributing to this family's denial. They are missing so much and wasting so much time. You are an honorable doctor and a true gentleman.Has anyone considered a psych consult for this family??!BTW, sure wish you were my neurologist!! (migraines...ugh...)

This is such a sad reality....my grandma is 87 and still has her faculties, at least as far as my family possesses them. We've discussed her desires to be allowed to die naturally; she has a DNR and would likely haunt me into insanity if I allowed anyone to prolong her suffering when the time comes. On the flipside, the "other" side of my family just experienced the loss of my grandfather...he was 91, had lived 30 years with barely controlled type-2 diabetes and survived innumerable heart attacks and diabetes-induced health issues. In the last two weeks of his life, his children all flew to his bedside and insisted all measures be taken to keep him alive. The details are vague (probably because I'm the rational-thinking black sheep and they don't like talking to me), but from what I understand he was in a coma he wouldn't return from! His wife (4th? 7th? I lost track a few wives in) finally insisted on removing him from life support, causing my aunts and uncles to hate her. I think it's actually pretty funny that he left everything to her. Serves them right for selfishly prolonging his suffering for their selfish reasons!

Good for you. It's sad when the family just can't let go. Right now my father-in-law is close to the end of a 6 year battle with ALS and my sister-in-law can't grasp this concept. The man has not been able to speak, eat or breath w/o a vent for almost 3 years. I say, let these unfortunate souls rest.

It's always good to see that there is a Doc out there with the integrity not to take money from idiots, even though they are practically begging to hand it out. I applaud you for having some decency, Dr. G!

Oh how sad. Whilst your decision is clearly the right one and I expect that you are correct about them being in denial. On the upside, isn't is wonderful that there are still families out there who still have that much love for their more senior members? How often do we hear tales of neglect and loneliness of our older generation? So let that call make you smile that at least one elderly lady has a loving family who are clearly distraught at the prospect of her imminent demise.

I just want to take the families side for a moment. They want as much done as they can. It is very hard to let go. If you talk to most families, they really have never experienced death. So, all they can do is hope. Hope that someone, will help them. The majority of the time, there is nothing more that can be done. A glimmer of hope, is what most people want.

Most are not like the rest of us, in the medical field. We see people suffering on a day to day basis. Most watch way too much TV, and they think a miracle could happen, (and I am sure they do, somewhere).

The best thing that happened to my grandmother when she was in the hospital after a massive stroke (it was at the back of the head -- she died 2 days later) was the compassionate clarity of the nursing staff that this really was the end, and to please keep that in mind when making resuscitation decisions.

I hope this family has someone in it who finally is able to see the facts through this blinding grief.

"How nice that some families still have that much love for their senior members..."

In my experience as a hospice nurse, the families most reluctant to let go are the ones who HAVE been neglectful, they're feeling guilty and realize that if Grandma dies they can never go back and prove what good chidren/grandchildren they really are.

Or, someone is living off of grandma and when she goes, the source of support goes.

Or, people are just fearful and to see grandma die reminds them that they will also die one day. They can't handle it, so they try to prevent it. (It's ALL about control at end-of-life, and how we don't have much....the biggest struggle in dying is learning to let go of the desire to control)...

These are just some cynical examples. Most/many families do their best to adapt to their loved one's disease process.

Even if I did, I don't think it's my job to provide "hope" - even though it's tempting to take the path of least resistance.

In my experience, most people want to hear the truth, explained with compassion in terms they can understand. The vast majority want to know they've done everything reasonable and when it's okay to let go... not too soon, and not too late, which is a different point for every family. Some of the most grateful families I know have thanked me for this input. It's the last gift I can give my patients when it's hopeless. (I'm known for being extremely aggressive when there is hope, incidentally, which probably helps my credibility.)

Mr. Tokyo (not real name, but close enough), who suffered his final ‘big one’ with TnI up to 60s, who had seen his brother suffer the ‘blue plate’ special 17 years ago (i.e. chest compressions and ACLS): he wanted nothing of it, DNR please. When undergoing his 3rd inguinal hernia repair he eventually suffered the ‘big one’ but his family (namely his new wife) refused to let go. He languished in the ICU for 3 weeks while he spiked his troponins if someone passed gas in the room, intubated and sedated. His wife insisted that ‘he will be singing Christmas carols’ by December. It was July. He died 2 days after I left the service, suffering through the ‘blue plate’ special after an attempt at a bed-side trach. I called my parents during this month and made sure they expressed their wishes, which is not to be kept alive if the person they would be was not who they were. I will let gratefully let them go in peace knowing they had not suffered through the indignity of ICU care. I hope I am never in that situation.

What really gets me is that these are the types of cases that the pt is still on Aricet, and familes swear it is actually doing something......then, hospice gets involved and we try to get them off of it, in vain.

I often wonder when people will realize that death is as much as part of life as living. It is selfish to think that our loved ones should go on without quality of life just so we don't have to feel the pain of saying goodbye.

My MIL spent almost 7 years in a nursing home with AD prior to her death in September, 2008. When we admitted her in 2001, I refused to fill out the full-code paperwork for my FIL, saying that I wouldn't be a party to torturing her. My husband was shocked, but I had a very frank conversation with both of them, saying that today was as good as it was ever going to be, and if she had a heart attack or another stroke, it would be best to let her go.

It took a year before my FIL came around to my way of thinking. She never did have any episode that would have made a decision necessary.

I haven't read the other posts, so I may be repeating someone else. Anyway, you're not obligated to do so but what if you did the consult and then sat down with these people to explain the torture they're putting their loved one through?

It's high time people learned to accept mortality in this country. I know it's difficult to lose someone but it is downright cruel to keep them alive just because they can't handle death.

I think too many people are watching House MD these days. It seems to be exactly what they are looking for: Surely there's a brilliant Dr. out there who can just give mama the right thing and she will be dancing rings around us in no time....

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

Singing Foo!

Have Dr. Grumpy delivered automatically to your Kindle for only 99 cents a month! Sign up here!

Dr. Grumpy is for hire! Need an article written (humorous, medical, or otherwise) or want to commission a genuine Grumpy piece for your newspaper/magazine/toilet paper roll? Contact me to discuss subjects. You can reach me at the email address below, or through my Linked-In profile.

Note: I do not answer medical questions. If you are having a medical issue, see your own doctor. For all you know I'm really a Mongolian yak herder and have no medical training at all except in issues regarding the care and feeding of Mongolian yaks.